HealthCombat Veterans are at risk for Complicated Grief in addition to PTSD

Combat Veterans are at risk for Complicated Grief in addition to PTSD

  • Definition
  • Risk Factors
  • Combat History
  • Treatment Options

Grief is a natural human reaction to the loss of a loved one, and can involve sadness, depression, and physical pain.

It is well known that combat experiences have a profound impact on the mental and physical health of veterans. Post-Traumatic Stress Disorder (or PTSD) is among the most commonly studied mental health problem following combat. However, less is known specifically about how loss of loved ones (such as close military peers or unit leaders) in a combat or deployment situation may impact veterans’ mental health.

Is this type of traumatic loss different in terms of its mental health consequences from that of PTSD? Or do these symptoms fit within PTSD? Research indicates there is a unique mental health syndrome that can follow traumatic loss that may appear similar to PTSD and depression in many ways, but also has its own unique clinical profile. It is called Complicated Grief (CG)1.

What is Complicated Grief?

For most people, the intensity of acute grief begins to subside in the first six months or so after a loss. But, some people do not begin to recover from the loss, and this is when complicated grief, also known as “traumatic grief”, or “prolonged grief” may occur. An individual may be considered to experience complicated grief if they also experience persistent yearning, longing, and sorrow after the death of the loved one for at least 12 months (6 for children). In addition, individuals must also report experiencing at least 6 of the following2:

      1. significant difficulty accepting the death
      2. disbelief over the loss
      3. difficulty with positive reminiscing about the deceased
      4. anger
      5. self-blame
      6. avoidance of reminders of the loss
      7. social/identity disruption

CG is associated with negative impact on physical and mental health3.

Risks for Developing CG

Research suggests people are at more relative risk of developing CG after a loss if they have a history of child abuse, neglect, or child separation anxiety and insecure attachments4-6, or if the loss occurred in a violent context7. Conversely, people are at relatively lower risk for developing CG if they had advance notice to prepare for the loss, and a strong social support network and higher technological connectedness (such as use of email)8.

How is CG different from PTSD?

Some of the symptoms may seem similar between CG and PTSD, such as experiencing negative feelings like guilt, fear, and shame, and potentially having difficulty trusting and feeling close to others. However, there are some key points of difference.

People with complicated grief are unlikely to be primarily focused on avoiding reminders of the loss of their loved ones; rather they may be preoccupied with and hyper-focused on thoughts of their loved one. This is a key difference because in PTSD, trauma survivors are likely making significant efforts to avoid people, places, or situations that remind them of the trauma, or thoughts and feelings about the trauma.

In addition, a key feature of CG is longing and yearning for the loved one, and this is not typically considered a feature of PTSD. Importantly, while PTSD and CG may be distinct clinical syndromes, research on civilian trauma survivors from 9/11, indicates that experiencing trauma can increase the risk for developing CG twofold4.

Combat Loss and CG

There is a lack of research on complicated grief among combat veterans, especially within the recently returning cohort (Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn Veterans). However, Papa and colleagues highlight research on Viet Nam combat veterans that indicates Viet Nam combat veterans endorsed higher grief symptoms than civilians who had recently lost a spouse. In addition, data from the National Viet Nam Veterans Readjustment study indicated that 860 out of 1636 veterans reported losing a close friend in combat, and these veterans reported worse grief symptoms and worse PTSD symptoms compared to veterans who did not lose a close friend in combat9.

While many features of combat in Viet Nam and recent conflicts may be similar suggesting that rates of complicated grief may be similar in more recent veterans, such as combat involving guerilla-style tactics, there are also some important differences. Viet Nam veterans were drafted, and we currently have an all-volunteer military. It would be important to examine how the act of volunteering for service may impact veteran’s experiences of guilt after a traumatic loss.

In addition, many Viet Nam war veterans were treated with notable hostility and alienation after returning home, and PTSD was not a formal diagnosis at that time. More recently returning veterans may have access to more formal mental health care resources than Viet Nam era veterans due to the now burgeoning area of research into PTSD, readjustment from combat, and related-treatments. However, actually accessing that care is wrought with challenges due to logistical and stigma-related barriers to care.

There are two important factors to consider that may put veterans more at risk for complicated grief that civilians:

      • the sudden, violent nature of loss in combat situation
      • the importance of cohesion in military culture.

Given how close military bonds can become, the loss can be that much more devastating. These are important factors to consider when trying to treat or support a veteran who may be grieving, and when trying to prevent the development of complicated grief for people at high risk.

Treatment Options

To date, there are no veteran-specific treatments developed for CG. Therefore, treatment recommendations pull from the existing civilian research on this topic, which supports using a targeted complicated grief treatment (CGT) approach developed by Shear and colleagues. CGT helps people develop tools to manage painful intrusive memories or thoughts of the loss to process it more fully, and reduce any avoidance of meaningful activities in life due to the loss.

In addition, treatment focuses on helping grieving individuals re-establish meaningful relationships, and works to help restore functioning in other important life areas. In this way, treatment integrates aspects of interpersonal and cognitive behavioral therapy for PTSD and depression, with a grief model. In addition, grief support groups early on in the grieving process may also be helpful10.


1 – Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel, B. (2007). Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. Journal of Abnormal Psychology, 116(2), 342-351. doi:10.1037/0021-843X.116.2.342

2 – Shear, M. K. (2015). Complicated grief. The New England Journal of Medicine, 372(2), 153-160. doi:10.1056/NEJMcp1315618

3 – Ott, C. H. (2003). The impact of complicated grief on mental and physical health at various points in the bereavement process. Death Studies, 27(3), 249-272. doi:10.1080/07481180302887

4 – Neria, Y., Gross, R., Litz, B., Maguen, S., Insel, B., Seirmarco, G., & … Marshall, R. D. (2007). Prevalence and psychological correlates of complicated grief among bereaved adults 2.5-3.5 years after September 11th attacks. Journal of Traumatic Stress, 20(3), 251-262. doi:10.1002/jts.20223

5 – Silverman, G. K., Johnson, J. G., & Prigerson, H. G. (2001). Preliminary explorations of the effects of prior trauma and loss on risk for psychiatric disorders in recently widowed people. Israel Journal of Psychiatry And Related Sciences, 38(3-4), 202-215.

6 – Vanderwerker, L. C., Jacobs, S. C., Parkes, C. M., & Prigerson, H. G. (2006). An exploration of associations between separation anxiety in childhood and complicated grief in later life. Journal of Nervous And Mental Disease, 194(2), 121-123. doi:10.1097/01.nmd.0000198146.28182.d5

7 – Barry, L. C., Kasl, S. V., & Prigerson, H. G. (2002). Psychiatric disorders among bereaved persons: The role of perceived circumstances of death and preparedness for death. The American Journal of Geriatric Psychiatry, 10(4), 447-457. doi:10.1176/appi.ajgp.10.4.447

8 – Vanderwerker, L. C., & Prigerson, H. G. (2004). Social Support and Technological Connectedness as Protective Factors in Bereavement. Journal of Loss And Trauma, 9(1), 45-57. doi:10.1080/15325020490255304

9 – Papa, A., Neria, Y., & Litz, B. (2008). Traumatic bereavement in war veterans. Psychiatric Annals, 38(10), 686-691. doi:10.3928/00485713-20081001-07

10 – Shear, M. K., & Gribbin Bloom, C. (2016). Complicated grief treatment: An evidence-based approach to grief therapy. Journal of Rational-Emotive & Cognitive-Behavior Therapy, doi:10.1007/s10942-016-0242-2

Research Psychologist at VA Boston Healthcare System

Sarah Krill Williston is a PhD Candidate at the University of Massachusetts Boston, working in the Roemer lab. Her research centers on boosting mental health literacy and reducing stigma to encourage evidence-based care-seeking for anxiety and trauma-related disorders. Sarah specializes in offering evidence-based treatments like CBT and ABBT to individuals, particularly military families, active duty service members, and veterans with mood, anxiety, and trauma-related disorders.


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